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McLaren Health Plan: Your Choice for Michigan Health Insurance|McLaren Health Plan|Members|Forms & Documents|Medicaid and Healthy Michigan Plan New Member Survey

McLaren Health Plan
Medicaid and Healthy Michigan Plan New Member Survey

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Medicaid and Healthy Michigan Plan New Member Survey

* Indicates required information

Name: *

Member ID: *

Date of Birth: *

Gender: *

Ethnicity:

Address: *

City: *

State: *

Zip: *

Phone Number: *

In the past month, did anxiety keep you from doing your usual activities, like work, school or a hobby?

Yes

No

In the past month did depression keep you from doing your usual activities, like work, school, or a hobby?

Yes

No

In the past 3 months, was there a time when you needed to see a doctor but could not because it cost too much?

Yes

No

In the past 3 months, have you had to eat less than you feel you should because there is not enough food?

Yes

No

Is it hard to find work or another source of income to meet your basic needs?

Yes

No

Are you worried that in the next few months, you may not have housing?

Yes

No

Stress is when someone feels tense, nervous, anxious or can’t sleep at night because their mind is troubled. Are you often stressed in your day to day life activities?

Yes

No

Do you think completing more education or training, like finishing a GED, going to college, or learning a trade, would be something you would like to work on in the next 6 months?

Yes

No

Do you have trouble getting to school, work or the store because you don’t have a way to get there?

Yes

No

In the past 3 months, have you had a hard time paying your utilities?

Yes

No

Have you been a patient in the Emergency Room 2 or more times in the past 6 months?

Yes

No

Do you need help finding a doctor?

Yes

No

Are any of your needs urgent?

Yes

No

If you have needs that make being healthy difficult, would you like someone from our team to help you with those needs?

Yes

No

Disclaimer: This survey is optional and will not affect any services or benefits you receive.

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Page Updated: 3/21/2023 7:06:38 PM

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McLaren Health Plan Medicaid and Healthy Michigan Plan New Member Survey

Medicaid and Healthy Michigan Plan New Member Survey

McLaren Health Plan
Medicaid and Healthy Michigan Plan New Member Survey